Questions & Answers

Heart disease in Indians often strikes earlier—and even at lower cholesterol levels or body weight. That’s why it’s vital to start heart-healthy habits early: avoid tobacco, eat a balanced diet, exercise regularly, get enough sleep, and maintain a healthy weight, waistline, blood sugar, blood pressure, and cholesterol.
Early detection saves lives. Screening for lipid disorders in childhood, assessing coronary artery calcium (CAC) or heart scans in adults, and using preventive medications when appropriate can uncover risks long before symptoms appear.
Know your risk before it’s too late. Don’t wait for chest pain—protect your heart today.

1. How and when did you get interested in heart disease in young Indians?
In the 1970s and 1980s, I cared for several young colleagues in their 20s to 40s who suffered massive heart attacks, without the usual risk factors, resulting in death or lifelong disability. Seeing these preventable tragedies sparked my lifelong focus on early heart disease in Indians. I dedicated my life to unraveling the enigma and mitigate the risk.

While planning and preparing for the Coronary Artery Disease in Indians (CADI) study, I noted sporadic reports showing higher heart disease rates in people of Indian descent compared to Europeans in the United Kingdom and Singapore but none from the United States. My leadership roles in national associations of physicians of Indian origin—such as the Association of Kerala Medical Graduates (AKMG) and the American Association of Physicians of Indian Origin (AAPI)—indicated that Indian-American doctors may have disproportionately higher rates of heart bypass surgery. I began writing on this topic early in the AAPI Journal (1990) followed by the American Journal of Cardiology (1992), Clinical Cardiology (1995), and Indian Heart Journal (1996).

We reported the results of the CADI study on nearly 2,000 Indian physicians attending the AAPI convention in Chicago (1996). It showed that heart disease rates among Indian men were three times higher than in whites, despite similar or lower rates of smoking, obesity, high blood pressure, and high cholesterol. Diabetes, although more common among Indians, failed to explain the heightened vulnerability to heart disease in Indians. Subsequently, two large prospective studies from the United Kingdom ̶ the LOLIPOP study and the UK Biobank study have confirmed our seminal findings confirming the Indian Paradox.

The Indian Paradox describes the disproportionately high rates of heart disease among Indians despite the absence of elevated levels of traditional risk factors such as cholesterol, blood pressure, or obesity. This anomaly suggested the influence of an underlying genetic factor.

With the collaboration of Thomas Pearson, Steven Haftner, Salim Yusuf, and Sonia Anand, we were the first to report elevated lipoprotein(a) [Lp(a)] levels in about 25% of Indians. Subsequent research by others has consistently confirmed that Lp(a) concentrations vary widely by ethnicity and that the Lp(a) levels in Indians are ~60% higher than in whites and ~100% higher than in the Chinese.

The INTERHEART Lp(a) study (2019) further established that Indians carry the highest risk of heart attack among the seven major ethnic groups worldwide and underscored the role of Lp(a) as a key contributor to premature heart attack in this population.

Lipoprotein(a) [Lp(a)] is among the most potent genetic risk factors for early heart disease. Lp(a) levels are set at birth, stabilize by the age of five, and remain high for life—quietly injuring the arteries year after year. In contrast to LDL cholesterol—which tends to rise later in life—elevated Lp(a) remains persistently high throughout life, silently accelerating atherosclerosis from a young age. When high Lp(a) coexists with elevated LDL cholesterol or diabetes, plaque buildup intensifies, often leading to heart attacks in the 20s or 30s.

• Lp(a) vs. Diabetes: Lp(a) alone doubles the risk of heart attack, and when combined with diabetes, the risk increases fourfold. Unlike diabetes, which usually appears in midlife, elevated Lp(a) is present from early childhood, silently accelerating artery damage decades earlier.
• Lp(a) vs. LDL Cholesterol: Lp(a) is a genetic variant of LDL that is 3–6 times more potent in promoting plaque buildup. When both Lp(a) and LDL are elevated, the risk of early heart attack can rise up to twelvefold—often striking in the prime of life.

Early heart attacks among Indians result from a dangerous combination of factors:
• Genetically determined high Lp(a)
• Increased prevalence of metabolic syndrome
• Early onset of diabetes, high LDL cholesterol, high blood pressure, and obesity
• Widespread lack of primordial prevention—healthy diet , regular exercise, and weight control are not established early in life
• Deficiencies in primary prevention.

• Primordial prevention: Prevent heart disease before risk factors appear by adopting healthy habits—balanced diet, regular exercise, avoiding tobacco, adequate sleep, and maintaining a healthy weight and waistline.
• Primary prevention: Control existing risk factors with lifestyle changes and medications to achieve guideline-recommended targets of cholesterol, blood pressure , blood sugar and cholesterol. In India, fewer than 1 in 8 adults have well-controlled risk factors, compared to 60–70% in countries like the US and Canada.
• Secondary prevention: Use a combination of four key classes of medications to prevent recurrent heart attacks in individuals with known heart disease.
• Tertiary prevention: Rapidly restore blood flow in acute heart attacks (STEMI) with stents or thrombolytic therapy, alongside ongoing medical management to minimize damage and prevent complications.

Don’t be misled by “normal” cholesterol. Even when cholesterol levels appear normal, LDL particles may carry high amounts of Lp(a), which is far more harmful. When triglycerides rise, another dangerous type—remnant cholesterol—also increases, while LDL may appear lower. This creates a false sense of security, hiding real risk to your heart.
Don’t be misled by “normal BMI“. BMI, a commonly accepted measure to judge ideal body weight, is not reliable in Indians. Even at lower weight and waistline, Indians remain at risk. Indians tend to have less muscle and more abdominal (visceral) fat, which often builds up in the liver, pancreas, and kidneys, raising the risk of heart disease even at modest body weight. This hidden fat leads to unhealthy levels of triglycerides, HDL cholesterol, blood sugar, and blood pressure—the key components of metabolic syndrome. Nearly one-third of Indian men and one-half of Indian women have this condition—the common soil for both diabetes and heart disease. This is why many Indians suffer heart attacks at 30 pounds lower body weight—and with smaller waistlines—than people in Western countries.

Over the past five decades, the United States has reduced heart disease deaths by nearly 80% and delayed the first heart attack to the late sixties and seventies—despite rising rates of obesity and diabetes. This remarkable success came from a comprehensive focus on primordial, primary, secondary, and tertiary prevention.
In contrast, India continues to face heart attacks in the forties, fifties, and sixties, largely because prevention is still not prioritized. The good news is that early detection can change this story. Coronary Artery Calcium (CAC) scans uncover silent heart disease that treadmill tests often miss:
• CAC 1-99 → Statin therapy is optional depending on the risk factor burden
• CAC ≥100 → Statin therapy recommended
• CAC ≥300 → Risk equals that of a heart attack survivor; needs aggressive prevention including high-intensity statin therapy
Three key tests can save Indian lives:
1. Age 10: Lipid profile—total cholesterol, triglycerides, VLDL (remnant cholesterol), non-HDL cholesterol, and ideally Lp(a)
2. Age 30–40: Heart scan (CAC score) to detect hidden disease early
3. Repeat as needed based on risk factors and family history
Early detection transforms destiny. Know your risk early, act decisively, and prevent the tragedy of a heart attack before it strikes.